Annals for Hospitalists - March 2023
Authors: David H. Wesorick
Journal: Annals of Internal Medicine (2023)

Web ExclusivesMarch 2023Annals for Hospitalists - March 2023FREEDavid H. Wesorick, MDDavid H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202303210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls–Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis in Persons Who Inject Drugs—Larry M. Baddour, MD, and Daniel C. DeSimone, MDSome persons who inject drugs may be candidates for long-term, outpatient, intravenous antibiotic treatment. This article discusses criteria for when this may be safe and the importance of concomitant medical treatment for opioid use disorder.Highlights of Recent Articles From Annals of Internal MedicineImplantable Defibrillator System Shock Function, Mortality, and Cause of Death After Magnetic Resonance ImagingAnn Intern Med. 2023;176:289-297. Published 31 January 2023. doi:10.7326/M22-2653This is a single-center, prospective, cohort study that enrolled consecutive patients with nonmagnetic resonance imaging (MRI)–conditional implantable cardioverter-defibrillators (ICDs) (n = 629) undergoing 1.5-Tesla MRI examinations (n = 813) in order to examine subsequent ICD function and patient outcomes. After the MRI, 536 patients had ICD interrogations. In these patients, over a median follow-up of 2.2 years, there were 4177 arrhythmic episodes and 10 arrythmia-related cardiac deaths. In all cases, these episodes were detected and treated appropriately, suggesting that there was no ICD dysfunction related to the MRI. Of note, there were 14 deaths of unclear cause, and about 1 in 4 of the causes of death were adjudicated on the basis of the death certificates alone.Key points for hospitalists include:These data challenge the hypothesis that 1.5-Tesla MRI scans degrade the function of non–MRI-conditional ICDs, as no ICD dysfunction was detected after MRI scanning in this study.With a loss to follow-up of 5%, a lack of post-MRI interrogations in 15%, and an imperfect process for adjudicating cause of death, the possibility of uncommon, undetected ICD failures cannot be entirely excluded.In the Clinic: Cardiac AmyloidosisAnn Intern Med. 2023;176: ITC33-ITC48. Published 14 March 2023. doi:10.7326/AITC202303210This narrative review article provides an updated overview of the screening, diagnosis, and treatment of cardiac amyloidosis, focusing on the 2 most common causes: light chain amyloid ([AL] caused by clonal expansion of B cells) and transthyretin amyloid ([ATTR] which can be caused by inherited mutations in the TTR gene, or occur in older patients despite normal genes).Key points for hospitalists include:It is estimated that 15% of patients with heart failure with preserved ejection fraction have a form of cardiac amyloidosis. Therefore, the condition should be strongly suspected in this patient population, especially if the patient has other findings that may be consistent with amyloidosis, such as peripheral or autonomic neuropathy, carpal tunnel syndrome, left ventricular hypertrophy (without a clear cause, such as chronic hypertension), significant proteinuria, macroglossia, or a known gammopathy.When suspected, the diagnostic approach should be guided by an algorithm and may include testing for monoclonal gammopathy, imaging (including echocardiography; cardiac MRI; and bone scintigraphy, which can detect ATTR deposition in the heart), and possible tissue sampling (for example, bone marrow biopsy, endomyocardial biopsy). Referral to a cardiologist can facilitate diagnostic testing.Treatment of cardiac amyloid includes offering treatment for heart failure, along with treatment to arrest the amyloid deposition. Typical heart failure medications are often poorly tolerated by patients with cardiac amyloidosis, and enrollment in a heart failure clinic may be helpful. AL amyloidosis is treated with chemotherapy, in consultation with a hematologist, and ATTR amyloidosis can be treated with medications that interfere with the production or abnormal folding of TTR, including a TTR stabilizer called tafamidis.The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice GuidelineAnn Intern Med. 2023;176:388-397. Published 14 February 2023. doi:10.7326/M22-2917This article summarizes the major recommendations from a recent U.S. Department of Veterans Affairs and U.S. Department of Defense guideline on the use of opioids in the management of chronic pain.Key points for hospitalists include:The guideline recommends against the use of opioid medications in the management of chronic noncancer pain.However, the guideline also recommends that if clinicians are considering prescribing long-term opioids for the treatment of chronic pain, that the patients should be screened for behavioral health conditions to identify those at higher risk for negative outcomes, and buprenorphine should be prescribed, instead of a full agonist opioid, because of lower risk for overdose and misuse of this medication. Editorialists point out that the recommendation to use buprenorphine for the management of chronic noncancer pain is radical given the limited supporting evidence in patients without opioid use disorder. Moreover, these recommendations seem to suggest that there may be some patients with chronic pain for whom the benefits of long-term opioids (specifically buprenorphine) may outweigh the risks, a possible paradigm change that may ultimately increase the number of patients taking long-term opioids.The Latest Highlights From Journal ClubIs cefepime–enmetazobactam as safe and effective as piperacillin–tazobactam in patients with complicated urinary tract infections (UTIs)?In complicated UTI or pyelonephritis, cefepime–enmetazobactam increased success vs. piperacillin–tazobactam at 14 dAnn Intern Med. 2023;176:JC21. doi:10.7326/J22-0114This randomized controlled noninferiority trial compared cefepime–enmetazobactam with piperacillin–tazobactam for the treatment of complicated UTI or pyelonephritis and found that the clinical cure rates were similar between the groups, but the cefepime–enmetazobactam group had a significantly higher rate of complete eradication of the cultured organism from the urine.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David H. Wesorick, MDAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Disclosures:Author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2807.* The authors contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis in Persons Who Inject Drugs Larry M. Baddour and Daniel C. DeSimone Metrics March 2023Volume 176, Issue 3 ePublished: 21 March 2023 Issue Published: March 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...